Identification of a common polymorphism in COQ8B acting as a modifier of thoracic aortic aneurysm severity.

Thoracic aortic aneurysm (TAA) predisposes to sudden, life-threatening aortic dissection. The factors that regulate interindividual variability in TAA severity are not well understood. Identifying a molecular basis for this variability has the potential to improve clinical risk stratification and advance mechanistic insight. We previously identified COQ8B, a gene important for biosynthesis of coenzyme Q, as a candidate genetic modifier of TAA severity. Here, we investigated the physiological role of COQ8B in human aortic smooth muscle cells (SMCs) and further tested its genetic association with TAA severity. We find COQ8B protein localizes to mitochondria in SMCs, and loss of mitochondrial COQ8B leads to increased oxidative stress, decreased mitochondrial respiration, and altered expression of SMC contractile genes. Oxidative stress and mitochondrial cristae defects were prevalent in the medial layer of human proximal aortic tissues in patients with TAA, and COQ8B expression was decreased in TAA SMCs compared with controls. A common single nucleotide polymorphism (SNP) rs3865452 in COQ8B (c.521A>G, p.H174R) was associated with decreased rate of aortic root dilation in young patients with TAA. In addition, the SNP was less frequent in a second cohort of early-onset thoracic aortic dissection cases compared with controls. COQ8B protein levels in aortic SMCs were increased in TAA patients homozygous for rs3865452 compared with those homozygous for the reference allele. Thus, COQ8B is important for aortic SMC metabolism, which is dysregulated in TAA, and rs3865452 may decrease TAA severity by increasing COQ8B level. Genotyping rs3865452 may be useful for clinical risk stratification and tailored aortopathy management.

An Emergent Nexus between Striae and Thoracic Aortic Dissection.

Current approaches to stratify the risk for disease progression in thoracic aortic aneurysm (TAA) lack precision, which hinders clinical decision making. Connective tissue phenotyping of children with TAA previously identified the association between skin striae and increased rate of aortic dilation. The objective of this study was to analyze associations between connective tissue abnormalities and clinical endpoints in adults with aortopathy. Participants with TAA or aortic dissection (TAD) and trileaflet aortic valve were enrolled from 2016 to 2019 in the setting of cardiothoracic surgical care. Data were ascertained by structured interviews with participants. The mean age among 241 cases was 61 ± 13 years. Eighty (33%) had history of TAD. While most participants lacked a formal syndromic diagnosis clinically, connective tissue abnormalities were identified in 113 (47%). This included 20% with abdominal hernia and 13% with skin striae in atypical location. In multivariate analysis, striae and hypertension were significantly associated with TAD. Striae were associated with younger age of TAD or prophylactic aortic surgery. Striae were more frequent in TAD cases than age- and sex-matched controls. Thus, systemic features of connective tissue dysfunction were prevalent in adults with aortopathy. The emerging nexus between striae and aortopathy severity creates opportunities for clinical stratification and basic research.

Outcomes of Surgical Coronary Revascularization Performed Before Solid Abdominal Organ Transplants.

BACKGROUND: Cardiac risk stratification and coronary angiography are routinely performed as part of kidney and liver transplant candidacy evaluation. There are limited data on the outcomes of surgical coronary revascularization in this patient population. This study investigated outcomes in patients with end- stage renal or hepatic disease who were undergoing coronary artery bypass grafting (CABG) to attain kidney or liver transplant candidacy. METHODS: This study was a retrospective analysis of all patients who underwent isolated CABG at our institution, Indiana University School of Medicine (Indianapolis, IN), between 2010 and 2016. Patients were divided into 2 cohorts: pretransplant (those undergoing surgery to attain renal or hepatic transplant candidacy) and nontransplant (all others). Baseline characteristics and postoperative outcomes were compared between the groups. RESULTS: A total of 1801 patients were included: 28 in the pretransplant group (n = 22, kidney; n = 7, liver) and 1773 in the nontransplant group. Major adverse postoperative outcomes were significantly greater in the pretransplant group compared with the nontransplant group: 30-day mortality (14.3% vs 2.8%; P = .009), neurologic events (17.9% vs 4.8%; P = .011), reintubation (21.4% vs 5.8%; P = .005), and total postoperative ventilation (5.2 hours vs 5.0 hours; P = .0124). The 1- and 5-year mortality in the pretransplant group was 17.9% and 53.6%, respectively. Of the pretransplant cohort, 3 patients (10.7%) underwent organ transplantation (all kidney) at a mean 436 days after CABG. No patients underwent liver transplantation. CONCLUSIONS: Outcomes after CABG in pre-kidney transplant and pre-liver transplant patients are poor. Despite surgical revascularization, most patients do not ultimately undergo organ transplantation. Revascularization strategies and optimal management in this high-risk population warrant further study.

Impact of troponin I level on coronary artery bypass grafting outcomes.

PURPOSE: The effect of preoperative cardiac troponin level on outcomes after coronary artery bypass grafting (CABG) is unclear. We investigated the impact of preoperative cardiac troponin I (cTnI) level as well as the time interval between maximum cTnI and surgery on CABG outcomes. METHODS: All patients who underwent isolated CABG at our institution between 2009 and 2016 and had preoperative cTnI level available were identified using our Society of Thoracic Surgeons registry. Receiver operating characteristic (ROC) analysis was performed to identify a cTnI threshold level. Subjects were divided into groups based on this value and outcomes compared. RESULTS: A total of 608 patients were included. ROC analysis identified 5.74 µg/dL as the threshold value associated with worse postoperative outcomes. Patients with peak cTnI >5.74 µg/dL underwent CABG approximately 1 day later, had twice the risk of adverse postoperative events, and had 2.8 day longer postoperative length of stay than those with peak cTnI ≤5.74 µg/dL. cTnI level was not associated with mortality or 30-day readmission. Time interval between peak cTnI and surgery did not affect outcomes. CONCLUSION: Elevated preoperative cTnI level beyond a certain threshold value is associated with adverse postoperative outcomes but is not a marker for increased mortality. Time from peak cTnI does not affect postoperative outcomes or mortality and may not need to be considered when deciding timing of CABG.

The presence of a dedicated cardiac surgical intensive care service impacts clinical outcomes in adult cardiac surgery patients.

BACKGROUND: Postoperative critical care management is an integral part of cardiac surgery that contributes directly to clinical outcomes. In the United States there remains considerable variability in the critical care infrastructure for cardiac surgical programs. There is little published data investigating the impact of a dedicated cardiac surgical intensive care service. METHODS: A retrospective study examining postoperative outcomes in cardiac surgical patients before and after the implementation of a dedicated cardiac surgical intensive care service at a single academic institution. An institutional Society of Thoracic Surgeons database was queried for study variables. Primary endpoints were the postoperative length of stay, intensive care unit length of stay, and mechanical ventilation time. Secondary endpoints included mortality, readmission rates, and postoperative complications. The effect on outcomes based on procedure type was also analyzed. RESULTS: A total of 1703 patients were included in this study-914 in the control group (before dedicated intensive care service) and 789 in the study group (after dedicated intensive care service). Baseline demographics were similar between groups. Length of stay, mechanical ventilation hours, and renal failure rate were significantly reduced in the study group. Coronary artery bypass grafting patients observed the greatest improvement in outcomes. CONCLUSIONS: Implementation of a dedicated cardiac surgical intensive care service leads to significant improvements in clinical outcomes. The greatest benefit is seen in patients undergoing coronary artery bypass, the most common cardiac surgical operation in the United States. Thus, developing a cardiac surgical intensive care service may be a worthwhile initiative for any cardiac surgical program.

Eleven-Year Experience Treating Blunt Thoracic Aortic Injury at a Tertiary Referral Center.

BACKGROUND: Blunt thoracic aortic injury treatment has evolved over the past decade particularly with respect to endovascular intervention options. We investigated the trends in blunt thoracic aortic injury management and outcomes over an 11-year span at the sole tertiary referral center in our state. METHODS: We retrospectively reviewed all patients who presented to our institution with blunt traumatic aortic injury between 2007 and 2017. Baseline demographics including aortic injury grade, injury severity score, and abbreviated injury scale were collected. Outcomes were compared by type and timing of treatment, which included either nonoperative management, endovascular repair, or open surgical repair. Bivariate and multivariable analyses were performed to examine treatment group differences and factors associated with 30-day mortality. RESULTS: In total, 229 patients were reviewed. The distribution of injury severity was grade 1 (30%), grade 2 (8%), grade 3 (30%), and grade 4 (31%). Overall, 27% of patients underwent endovascular repair, 29% open surgery, and 44% definitive nonoperative management. Over the study period, there was a dramatic decline in open surgery and a corresponding rise in endovascular treatment. Thirty-day mortality for the entire cohort was 22%. Mortality by treatment subgroup was 30% for nonoperative management, 8.2% for endovascular treatment, and 21% for open surgery. Delaying endovascular or open surgical treatment by at least 24 hours after admission was associated with significantly improved 30-day survival. CONCLUSIONS: Procedural intervention, whether endovascular or surgical, is associated with improved mortality compared with nonoperative treatment. Delayed intervention, particularly in the case of high-grade injuries, may allow for initial patient stabilization and improved outcomes.

The Addition of Aortic Root Procedures During Elective Arch Surgery Does Not Confer Added Morbidity or Mortality.

BACKGROUND: During elective aortic arch replacement, the addition of an aortic root procedure has an unknown effect on morbidity and mortality. The purpose of this study is to determine the effect of adding an aortic root procedure to elective aortic surgery using the ARCH international database. METHODS: The ARCH Database was queried for all elective aortic arch replacements with and without aortic root replacement using moderate hypothermic circulatory arrest and antegrade cerebral perfusion from 2000 to 2015. Propensity score matching analysis was used to balance covariates, and a logistic regression model was created. RESULTS: A total of 1,169 patients were included for analysis, and 320 patients (27.4%) underwent an aortic root procedure. Patients undergoing root procedures were younger (69 versus 61 years), had less coronary artery disease (20% versus 32%), and had a higher incidence of Marfan's syndrome (4.2% versus 10.0%) (p < 0.001 for all). Concomitant coronary artery bypass grafting (26.6% versus 19.7%), total aortic arch replacement (41.6% versus 84.3%), and elephant trunk procedures (46% versus 17.2%) were performed more frequently in the nonroot cohort (p < 0.001 for all). Cardiopulmonary bypass and aortic cross-clamp times were significantly longer in the cohort of patients who underwent root procedures, whereas cerebral perfusion times were longer in the nonroot cohort (p < 0.001 for all). In both the propensity matched and nonmatched analyses, postoperative outcomes were not significantly different between patients who underwent root procedures and patients who did not (p > 0.05 for all outcomes). Multivariable logistic regression analyses showed no difference in mortality rates (odds ratio 0.62, 95% confidence interval: 0.9 to 1.34, p = 0.22) or in rates of permanent stroke (odds ratio 0.89, 95% confidence interval: 0.36 to 2.24, p = 0.81) between the root and nonroot cohorts. CONCLUSIONS: The addition of an aortic root procedure during elective aortic arch surgery lengthens cardiopulmonary bypass and aortic cross-clamp times but does not increase postoperative morbidity or mortality.

A 20-year multicenter analysis of dialysis-dependent patients who had aortic or mitral valve replacement: Implications for valve selection.

OBJECTIVE: Valve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection. METHODS: Dialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms. RESULTS: Four hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001). CONCLUSIONS: Dialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.

Repair of Thoracic and Thoracoabdominal Mycotic Aneurysms and Infected Aortic Grafts Using Allograft.

BACKGROUND: Mycotic aneurysm of the thoracic or thoracoabdominal aorta and infection of thoracic or thoracoabdominal aortic grafts are challenging problems with high mortality. In situ reconstruction with cryopreserved allograft (CPA) avoids placement of prosthetic material in an infected field and avoids suppressive antibiotics or autologous tissue coverage. METHODS: Fifty consecutive patients with infection of a thoracic or thoracoabdominal aortic graft or mycotic aneurysm underwent resection and replacement with CPA from 2006 to 2016. Intravenous antibiotics were continued postoperatively for 6 weeks. Long-term suppressive antibiotics were uncommonly used (8 patients). Follow-up imaging occurred at 6, 18, and 42 months postoperatively. Initial follow-up was 93% complete. RESULTS: Men comprised 64% of the cohort. The mean age was 63 ± 14 years. The procedures performed included reoperations in 37 patients; replacement of the aortic root, ascending aorta, or transverse arch in 19; replacement of the descending or thoracoabdominal aorta in 27; and extensive replacement of the ascending, arch, and descending or thoracoabdominal aorta in 4. Intraoperative cultures revealed most commonly Staphylococcus (24%), Enterococcus (12%), Candida (6%), and gram-negative rods (14%). Operative mortality was 8%, stroke was 4%, paralysis was 2%, hemodialysis was 6%, and respiratory failure requiring tracheostomy was 6%. Early reoperation for pseudoaneurysm of the CPA was necessary in 4 patients. One-, 2-, and 5-year survival was 84%, 76%, and 64%, respectively. CONCLUSIONS: Radical resection and in situ reconstruction with CPA avoids placing prosthetic material in an infected field and provides good early and midterm outcomes. However, early postoperative imaging is necessary given the risk of pseudoaneurysm formation.

Acute aortic syndrome.

Acute aortic syndrome (AAS) is a term used to describe a constellation of life-threatening aortic diseases that have similar presentation, but appear to have distinct demographic, clinical, pathological and survival characteristics. Many believe that the three major entities that comprise AAS: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU), make up a spectrum of aortic disease in which one entity may evolve into or coexist with another. Much of the confusion in accurately classifying an AAS is that they present with similar symptoms: typically acute onset of severe chest or back pain, and may have similar radiographic features, since the disease entities all involve injury or disruption of the medial layer of the aortic wall. The accurate diagnosis of an AAS is often made at operation. This manuscript will attempt to clarify the similarities and differences between AD, IMH and PAU of the ascending aorta and describe the challenges in distinguishing them from one another.

The ARCH Projects: design and rationale (IAASSG 001).

OBJECTIVE: A number of factors limit the effectiveness of current aortic arch studies in assessing optimal neuroprotection strategies, including insufficient patient numbers, heterogenous definitions of clinical variables, multiple technical strategies, inadequate reporting of surgical outcomes and a lack of collaborative effort. We have formed an international coalition of centres to provide more robust investigations into this topic. METHODS: High-volume aortic arch centres were identified from the literature and contacted for recruitment. A Research Steering Committee of expert arch surgeons was convened to oversee the direction of the research. RESULTS: The International Aortic Arch Surgery Study Group has been formed by 41 arch surgeons from 10 countries to better evaluate patient outcomes after aortic arch surgery. Several projects, including the establishment of a multi-institutional retrospective database, randomized controlled trials and a prospectively collected database, are currently underway. CONCLUSIONS: Such a collaborative effort will herald a turning point in the surgical management of aortic arch pathologies and will provide better powered analyses to assess the impact of varying surgical techniques on mortality and morbidity, identify predictors for neurological and operative risk, formulate and validate risk predictor models and review long-term survival outcomes and quality-of-life after arch surgery.

Open repair of chronic aortic dissections using deep hypothermia and circulatory arrest.

BACKGROUND: There has been great enthusiasm for thoracic endograft repair of chronic thoracic or thoracoabdominal aortic dissection (ChAD) given the low operative morbidity and mortality. However long-term results are unknown and early reintervention is common. This study examines the early and late results of open repair of ChAD using deep hypothermia and circulatory arrest (DHCA). METHODS: From January 1995 to December 2009, 343 patients had open repair of descending thoracic or thoracoabdominal aneurysms using DHCA. Of these individuals, 93 patients had open repair of ChAD with DHCA. All patients undergoing elective procedures underwent preoperative cardiac catheterization. Lumbar drains were not placed preoperatively. Visceral or renal artery bypass was performed in 20% of patients. Supraaortic branches were bypassed in 14% of patients. RESULTS: Mean age was 60 ± 14 years. Men composed 77% of the cohort. Aortic replacement encompassed the descending aorta in 29% of patients, type I thoracoabdominal repair was performed in 25% of patients, type II thoracoabdominal repair was performed in 40% of patients, and arch replacement was performed in 24% of patients. Operative mortality was 2.2%, renal failure requiring dialysis was 0%, paralysis occurred in 1.1% of patients, stroke occurred in 1.1% of patients, prolonged intubation was needed in 9.7% of patients, and tracheostomy was needed in 2.2% of patients. Postoperative length of stay was 10.5 ± 7.6 days. One-, 3-, 5-, and 10-year survival rates were 93%, 90%, 79%, and 61%, respectively. Reintervention was necessary in 2.2% of patients for graft infection, in 2.2% of patients for anastomotic pseudoaneurysm, and in 4.4% of patients for growth of a distal aortic aneurysm. CONCLUSIONS: Open repair of ChAD with DHCA has low operative morbidity and mortality. Long-term survival is very good with low rates of reintervention. Endovascular repair of ChAD does not have proven short- or long-term efficacy.

Total arch and descending thoracic aortic replacement by left thoracotomy.

BACKGROUND: The hybrid treatment of transverse aortic arch pathologies with supraaortic debranching and endovascular repair is associated with significant morbidity and death and lacks long-term follow-up. The traditional two-stage open surgical approach to extensive arch and descending thoracic aneurysms carries a significant interval mortality rate. We report the results of a single-stage technique of total arch and descending thoracic aortic replacement by a left thoracotomy. METHODS: From January 1995 to February 2011, 426 patients underwent thoracic or thoracoabdominal aneurysm repair, of which a highly selected group of 27 patients underwent total arch replacement with descending thoracic or thoracoabdominal aortic replacement. All procedures were performed with hypothermic circulatory arrest and selective antegrade cerebral perfusion. Two patients required transverse division of the sternum. Two patients had emergency or urgent operations. Five patients had concomitant coronary artery bypass, and 1 had concomitant mitral valve replacement. RESULTS: There were no hospital deaths, no cerebrovascular accidents, and one instance of transient spinal cord ischemia. Three patients had acute renal failure not requiring hemodialysis. Intubation in 5 patients exceeded 48 hours, and 1 patient needed tracheostomy. Two patients required reexploration for postoperative bleeding. Survival at 1, 3, and 5 years was 95%, 78%, and 73%, respectively. CONCLUSIONS: Replacement of the total arch and descending thoracic aorta by a left thoracotomy provides excellent short-term and long-term results for the treatment of extensive arch and thoracic aortic pathology, without the need for a second-stage operation. Other cardiac pathologies, such as left-sided coronary disease and mitral valve disease, can be addressed concurrently.

Long-term results with cryopreserved arterial allografts (CPAs) in the treatment of graft or primary arterial infections.

OBJECTIVE: Our purpose was to evaluate our results with CPAs in patients with infected grafts or primary arterial infection with emphasis on long-term durability of these grafts. METHODS: To evaluate the long-term durability of CPAs, clinical outcomes were analyzed following their use for either graft or primary arterial infections at a single institution over a 9-y period (2000-2009). The 30-d mortality rate, 90-d mortality rate, and the cause of early mortality were determined in each case. Among those surviving 90 d, the grafts were evaluated for subsequent failure. RESULTS: From 2000 through 2009, 51 patients with either infected prosthetic grafts (35) or primary arterial infections (15) received CPAs. One patient had infection of a previously placed thoracic allograft. Forty-three graft infections involved either the thoracic or abdominal aorta. Eleven patients presented with fulminant sepsis with systemic inflammatory response syndrome (SIRS), seven of whom died postoperatively. Eight patients presented with aorto-enteric, esophageal, or bronchial fistulae with infected prosthetic grafts. The 30-d mortality rate was 25.5% (11 deaths) seven of which occurred in patients with SIRS. The 90-d mortality rate was 41.4%. There were 10 graft failures, seven occurring in patients with aorto-enteric or bronchial fistulae all of whom had recurrent hemorrhage. The other three graft failures were due to anastomotic hemorrhage in the early postoperative period. Among those surviving 90 d, the mean follow-up was 46.4 mo (range 1-112 mo). No aneurysmal degeneration of the CPAs was noted. Only one subsequent allograft graft failure was noted among those surviving more than 90 d. CONCLUSIONS: CPAs are a suitable option in dealing with cardiovascular infections. Patients with enteric or bronchial fistulae are a difficult group to treat perhaps because of ongoing contamination of the allograft. The operative mortalities are largely determined by patient comorbidities (SIRS). Subsequent degeneration or infection of the CPAs is rare.

Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest.

OBJECTIVE: Open repair of descending thoracic aortic and thoracoabdominal aortic aneurysms may carry low morbidity and mortality, depending on experience of the surgeon and operative technique used. Although thoracic endovascular aortic repair is less invasive, its limitations include anatomy and pathology of the aorta, proximity of major branches, and significant complication and reintervention rates. We retrospectively reviewed a 2-surgeon experience (J.W.F. and J.S.C.) with deep hypothermic circulatory arrest to repair descending thoracic aortic and thoracoabdominal aortic aneurysms. METHODS: All patients (n = 343) who underwent surgical replacement of descending thoracic aortic or thoracoabdominal aortic aneurysm with deep hypothermic circulatory arrest from 1995 to 2009 were included. Segmental arteries between T8 and the celiac artery were aggressively reimplanted as indicated. Visceral and renal artery bypasses were performed for significant stenosis. Concomitant coronary artery bypass grafting was performed if targets were anterior or lateral wall vessels. Lumbar drains were not routinely used but placed postoperatively on clinical evidence of spinal cord ischemia. RESULTS: Of 343 patients, 98 had descending thoracic aortic aneurysms, 69 had Crawford type I thoracoabdominal aortic aneurysms, 111 had type II, 32 had type III, and 33 had type IV. Emergency or urgent operations comprised 13% of repairs. Hospital mortalities were 5.0% for all cases, 3.7% for elective cases, and 13.3% for urgent or emergency cases. Overall incidences were 4.4% for stroke, 3.2% for paraplegia or paraparesis, 1.5% for renal failure requiring dialysis, and 3.5% for tracheostomy. The 1-, 3-, 5-, and 10-year survival rates were 90%, 79%, 69%, and 54%, respectively. CONCLUSIONS: Surgical repair of descending thoracic aortic and thoracoabdominal aortic aneurysms with deep hypothermic circulatory arrest carries low operative morbidity and mortality and excellent early and late survival rates. These results can be used as a benchmark for future techniques and technologies.

Characteristics of second primary lung malignancy in patients with known breast cancer.

BACKGROUND: As breast cancer survival improves, the incidence of additional malignancies will likely rise. Identification of a lung nodule in a patient with known breast cancer poses a challenging diagnostic problem. This study outlines the management of such patients and identifies factors that correlate with survival. METHODS: From 1977 through 2002, 35 patients with known breast cancer were identified with an additional primary lung cancer. Data were collected from a retrospective chart review. Median and 2- year survival were determined by the Kaplan-Meier method and Cox regression analysis identified independent predictors of survival. RESULTS: Nineteen patients (54%) were asymptomatic at the time of diagnosis and had their lung cancer discovered during workup and/or follow-up of their breast cancer. The diagnosis of lung cancer was made by preoperative biopsy in 23 patients (82%). Nineteen patients (54%) were successfully treated with surgery. Mean follow-up was 2.3 years. Median survival for all patients was 1.8 years. Factors associated with a statistically significant improvement in survival included asymptomatic presentation of lung cancer (P = 0.003), absence of tobacco use (P = 0.021), and stage I lung cancer (P = 0.009). Multivariate analysis revealed that tobacco use (RR = 3.6, P = 0.047) and advanced stage of lung cancer (II-IV) at the time of diagnosis (RR = 2.2, P < 0.001) were independent predictors of decreased survival. CONCLUSION: The presentation of a lung nodule in patients with breast cancer warrants a comprehensive evaluation to differentiate between primary lung and metastatic breast cancers, as diagnosis and resection of an early stage lung cancer is associated with improved survival.

"Spot" ECGs Underestimate Atrial Fibrillation Recurrence After Surgical Ablation.

OBJECTIVE: : Historically, success of surgical treatment of atrial fibrillation (AF) has been measured by electrocardiograms (ECGs) at various intervals. However, continuous monitoring of cardiac rhythms by "autocapture" devices has recently become more available and convenient. The concordance of measurements of freedom from AF by these two techniques has not been reported after surgical ablation. METHODS: : Between August 2005 and May 2006, 47 patients at a single academic center underwent surgical ablation procedures for AF and had recurrence of AF assessed by both "spot" 12-lead ECG and autocapture event monitoring. Forty-one ablation procedures were concomitant with other cardiac surgery and six were stand alone, nonsternotomy procedures. Agreement between these diagnostic modes was measured using the κ statistic at 3, 6, and 12 months (κ of 1 is perfect agreement, 0 is no agreement). McNemar test was employed to determine whether agreement significantly changed from 3 to 12 months. RESULTS: : At 3 months follow-up, spot ECGs suggested that 81% (38 of 47) of surgical patients were free of any AF, whereas 1-week event recordings found only 70% (31 of 44) of patients were free of any AF. At 6 months, spot ECGs estimated that 87% (40 of 46) of surgical patients were free of AF; 1-week event recordings found only 74% (34 of 46) of patients were free of AF. At 12 months, spot ECGs estimated that 84% (26 of 31) of surgical patients were free of AF compared with only 68% (19 of 28) as measured by the 1-week event recorder. The κ measures (with 95% confidence interval) at 3, 6, and 12 months were 0.52 (0.24-0.80), 0.60 (0.32-0.87), and 0.63 (0.32-0.94) respectively, showing only moderate agreement. McNemar test showed no significant shift in agreement from 3 to 6 months (P = 0.7055), 3 to 12 months (P = 1.000), or 6 to 12 months (P = 1.000). There were no deaths or strokes, but one myocardial infarction among these 47 patients during 12 months follow-up. CONCLUSIONS: : "Spot" ECGs underestimate the incidence of recurrent AF after surgical ablation for AF and show poor agreement with the more reliable 1-week autocapture event recordings.

Minimally invasive surgical cardiac resynchronization therapy: an intermediate-term follow-up study.

BACKGROUND: : Cardiac resynchronization therapy (CRT) improves symptoms, quality of life, and ejection fraction in selected patients with congestive heart failure (CHF) and interventricular conduction delay. Transvenous insertion of left ventricular (LV) pacing leads via the coronary sinus is unsuccessful in 8-10% of patients. This study describes intermediate-term follow up of minimally invasive surgical techniques for CRT as a viable alternative after failed transvenous lead insertion. METHODS: : From March 2001 to October 2005, fifty-four patients with NYHA Class III-IV symptoms, QRS duration 181 ± 40 milliseconds, and LV ejection fraction 19.7 ± 8.0% underwent a total of 56 minimally invasive LV lead placements via thoracoscopic video assistance (n = 38) or minithoracotomy (n = 17). One patient required full thoracotomy after a previous video-assisted thoracoscopic procedure. Intraoperative transesophageal echocardiography was used to assess changes in LV function. RESULTS: : Acute thresholds for the active lead measured 1.10 ± 0.62 V, with R-wave amplitude of 12.3 ± 6.6 mV and impedance of 631 ± 185 Ohm. Thirty-day mortality was 5%. There were no perioperative myocardial infarctions or strokes. Five patients required transfusion, 3 had exacerbation of prior renal insufficiency, 5 had pulmonary complications, and 8 required inotropic support for more than 48 hours. Intermediate-term follow up (mean 20 ± 16 months, range 11 days to 55 months) revealed 3 patients with lead failure requiring additional surgical intervention. Hospitalization due to worsening CHF occurred in 5 patients, and 2 of these patients required intravenous inotropic support. QRS duration decreased to 146 ± 36 milliseconds postoperatively (P < 0.001). CONCLUSION: : Minimally invasive surgical lead placement safely and effectively accomplishes cardiac resynchronization using either thoracoscopic or minithoracotomy techniques.